The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Capillary refill, color of extremity.

Pedal pulses.

ACE wrap, Velcro boot, and hanging weights.

Pin sites.

Temperature, sensation, and movement of toes.

Answer and Explanation

Correct Answer : A,B,D,E

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

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Correct Answer is C

Explanation

Choice A Reason
The continuous nature of the mucosa refers to the uninterrupted lining of the urinary tract, which provides a barrier against pathogens. However, this characteristic is not a significant factor in the increased susceptibility of women to cystitis. Both men and women have a continuous mucosal lining, and it does not account for the gender difference in infection rates.

Choice B Reason
High estrogen levels can influence the tissues of the urinary tract and may affect susceptibility to infections. However, the role of estrogen in the development of cystitis is not as direct or significant as anatomical differences. Estrogen levels vary throughout a woman's life and do not consistently correlate with cystitis risk.

Choice C Reason
Urethral proximity to the rectum is the most significant anatomical factor contributing to a woman's increased susceptibility to cystitis¹⁴. Women have a shorter urethra than men, and its close proximity to the anus allows bacteria from the bowel area to more easily enter the urinary tract and cause infections.

Choice D Reason
Inadequate fluid intake can lead to less frequent urination, which is a risk factor for cystitis because it reduces the natural flushing of bacteria from the urinary tract. However, this is a modifiable risk factor and does not inherently explain the higher incidence of cystitis in women compared to men.

A. Switched to heparin. B. Given as prescribed. C. Increased. D. Held.

Correct Answer is A

Explanation

Choice A Reason:
Switching to heparin is not the standard response for a high INR. Heparin may be used in conjunction with warfarin when starting anticoagulation therapy, but it is not typically used as a substitute in response to an elevated INR.

Choice B Reason:
Giving the dose as prescribed would not be appropriate when the INR is significantly above the therapeutic range. Continuing the same dose could increase the risk of bleeding complications.

Choice C Reason:
Increasing the dose would be contraindicated as the INR is already too high. Increasing the warfarin dose would further elevate the INR and increase the risk of bleeding.

Choice D Reason:
Holding the dose is the correct action when the INR is significantly above the therapeutic range, which is generally between 2.0 to 3.0 for most indications. The healthcare provider should be notified, and the warfarin dose should be held until the INR returns to the therapeutic range. Vitamin K may also be administered to help lower the INR more quickly if necessary.

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The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When teaching a client about cystitis, the nurse explains that women are more prone to the infection than men. Which of the following best explains a woman's increased susceptibility?

Correct Answer is C

Explanation

The nurse has administered warfarin 2.5 mg orally daily for three days to a client who has deep vein thrombosis. The client's International Normalized Ratio (INR) today is 5.0. The nurse notifies the healthcare provider because today's dose of the medication should be:

Correct Answer is A

Explanation

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